Microvascular burden and long-term risk of stroke and dementia in type 2 diabetes mellitus

OBJECTIVE

To examine the associations between microvascular disease (MVD) and risk of stroke, dementia, and their major subtypes among individuals with type 2 diabetes mellitus (T2DM).

METHODS

We included 26,173 participants with T2DM from the UK Biobank who had no known stroke or dementia at baseline. MVD burden was reflected by the presence of retinopathy, peripheral neuropathy, and chronic kidney disease. Cox regression models were used to estimate hazard ratios (HRs) and 95 % confidential intervals (CIs) of stroke and dementia associated with overall MVD burden and individual MVD.

RESULTS

During a median follow-up of 11.5 years, 1103 incident stroke (964 ischemic and 269 hemorrhagic stroke) and 813 incident dementia (312 Alzheimer's disease and 304 vascular dementia) cases were identified. The risk of stroke, dementia, and their major subtypes all increased with an increasing number of MVD (all P-trend <0.001). The adjusted HRs (95 % CIs) comparing three with no MVD were 5.03 (3.16, 8.02) for all stroke, 4.57 (2.75, 7.59) for ischemic stroke, and 6.60 (2.65, 16.43) for hemorrhagic stroke. The corresponding estimates were 4.28 (2.33, 7.86) for all-cause dementia, 6.96 (3.02, 16.01) for Alzheimer's disease, and 3.81 (1.40, 10.42) for vascular dementia. Among the three MVD, chronic kidney disease showed the strongest associations with both stroke subtypes, while peripheral neuropathy was most strongly associated with both dementia subtypes.

CONCLUSIONS

Risk of stroke, dementia, and their major subtypes increased with an increasing number of MVD. The associations of individual MVD with stroke and dementia varied substantially by types of MVD.

Micro-vascular complications of post-transplant diabetes mellitus in renal transplant recipients- an observational study

INTRODUCTION

The incidence of post-transplant diabetes mellitus (PTDM) ranges from 2.5% to 20% in kidney transplant recipients. Diabetic retinopathy (DR), diabetic kidney disease (DKD), and distal symmetric polyneuropathy (DSPN) are the microvascular complications frequently seen in both type 1 and 2 diabetes mellitus (DM). However, the data regarding these complications in patients with PTDM is lacking.

METHOD

A retrospective and prospective observational study of PTDM conducted at a tertiary care hospital from November 2018 to December 2020. 115 kidney transplant recipients who had PTDM of ≥5 years duration were included and analysed.

RESULTS

The mean duration of PTDM was 8.8 ± 3.0 years, and the mean of all available HbA1c values was 7.0 ± 0.9%. while none of the patients had evidence of diabetic retinopathy on direct ophthalmoscopy, 37.4% of patients (n = 43) had DSPN and this was associated with the duration of PTDM and age. The mean estimated glomerular filtration rate (eGFR) was 59.24 ± 21.82 ml/min/1.73m2, and patients had a median proteinuria of 620 mg/day (IQR 1290). Out of 115 patients, 20% of them (n = 23) underwent graft kidney biopsy, and 10 biopsies were diagnosed as de-novo DKD. Patients with biopsy proven DKD had a mean PTDM duration of 143.3 ± 52.4 months; a mean HbA1c level of 7.9 ± 1.3%; a mean eGFR of 44.8 ± 21.8 ml/min; and a median proteinuria of 2653 mg (IQR 2758). An additional analysis of all 23 biopsied patients showed that HbA1c level and degree of proteinuria were significantly associated with de-novo DKD.

CONCLUSION

PTDM in transplant patients had milder microvascular complications than usually expected in Type 1/2 diabetes in non-transplant patients. DR was not strongly associated with DKD in PTDM patients. Furthermore, de-novo DKD development was associated with poor glycaemic control and increased proteinuria.

Relationship of microvascular complications and healthy lifestyle with all-cause and cardiovascular mortality in women compared with men with type 2 diabetes

BACKGROUND

Sex differences exist in the prevalence of microvascular disease (MVD) and healthy-lifestyle adherence. Whether MVD and healthy lifestyles are associated with mortality risk similarly for women and men who have type 2 diabetes mellitus (T2DM) remains unknown.

METHODS

The present study included 9992 women and 15,860 men with T2DM from the UK Biobank. MVDs included retinopathy, peripheral neuropathy, and chronic kidney disease. Healthy lifestyle factors consisted of ideal BMI, nonsmoking, healthy diet, regular exercise, and appropriate sleep duration. Sex-specific hazard ratios (HRs) of mortality associated with the MVDs or healthy lifestyles were calculated and women-to-men ratio of HRs (RHR) were further estimated, after multivariable adjustment for potential confounders.

RESULTS

During a median of 12.7 years of follow-up, 4346 (1202 in women) all-cause and 1207 (254 in women) CVD deaths were recorded. The adjusted HRs (95% CI) of all-cause mortality for 1 additional increment of the MVDs were 1.71 (1.55, 1.88) for women and 1.48 (1.39, 1.57) for men, with an RHR of 1.16 (1.03, 1.30). The corresponding RHR was 1.36 (1.09, 1.69) for cardiovascular mortality. Adhering to a healthy lifestyle (≥4 vs. ≤1 lifestyle factor) was associated with an approximately 60%-70% lower risk of all-cause and cardiovascular mortality without sex differences (P-interaction >0.70). Furthermore, as compared with having no MVD and an unfavorable lifestyle, having ≥2 MVDs but a favorable lifestyle was not associated with a higher risk of all-cause mortality either in women (HR = 0.88; 95% CI: 0.49, 1.60) or in men (HR = 0.95; 95% CI: 0.64, 1.40), similarly when considering cardiovascular mortality.

CONCLUSIONS

In T2DM, while MVDs are more strongly associated with mortality risk in women than in men, adhering to a favorable lifestyle is associated with a substantially lower risk of mortality and may eliminate the detrimental impact of MVDs in both sexes.

Gene Expression Analysis in T2DM and Its Associated Microvascular Diabetic Complications: Focus on Risk Factor and RAAS Pathway

Prolonged hyperglycemic conditions in type 2 diabetes mellitus (T2DM) cause pathological and functional damage to many organs and tissues, including the kidneys, retina, skin, and neuronal tissues, resulting in the development of microvascular diabetic complications. The altered renin angiotensin aldosterone system (RAAS) pathway has been reported to play an important role in the development of insulin resistance in T2DM and associated complications. The current study was carried out to evaluate the association of risk factors and altered expression of RAAS genes in T2DM patients without complications and T2DM patients with complications (retinopathy, nephropathy, and neuropathy). Four hundred and twenty subjects including 140 healthy controls, 140 T2DM patients with diabetic complications, and 140 T2DM patients without diabetic complications were included in the study. Risk factors associated with the development of T2DM and diabetic complications were evaluated. Further, expression analysis of RAAS genes (AGT, ACE, ACE2, and AGT1R) was carried out using qRTPCR in healthy controls, T2DM patients with complications, and T2DM patients without complications. Various risk factors like urban background, higher BMI, alcoholism, smoking, and family history of diabetes among others were found to be associated with the development of T2DM as well as diabetic complications. The expression level of AGT, ACE, and AGT1R was found to be upregulated whereas ACE2 was found to be downregulated in T2DM patients with complications and T2DM patients without complications as compared to controls. Altered expression of the studied genes of RAAS pathway is associated with the development of microvascular diabetic complications.

Remnant cholesterol is an independent risk factor for the incidence of chronic kidney disease in newly-diagnosed type 2 diabetes: A nationwide population-based study

AIMS

To evaluate the impact of remnant cholesterol (remnant-C) on chronic kidney disease (CKD) incidence in newly-diagnosed type 2 diabetes.

METHODS

This retrospective cohort study used Korean National Health Insurance Service data on 212,836 patients with newly-diagnosed type 2 diabetes between 2009 and 2014. We conducted cox regression analysis to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) for developing CKD according to remnant-C tertile.

RESULTS

During a median follow-up duration of 5.23 years, 6,850 CKD cases developed. In the fully adjusted model, HRs and 95 % CIs for incident CKD increased in the highest tertile of baseline remnant-C compared to the lowest (HR [95 % CI]; 1.234 [1.159-1.314]). This association was more prominent in patients with hypertension or low-income status (P for interaction < 0.05). Increased HRs in the highest tertile of remnant-C was sustained in type 2 diabetes patients within target range of conventional lipid profile such as low-density lipoprotein cholesterol (LDL-C) < 100 mg/dL and < 70 mg/dL (1.165 [1.041-1.304] and 1.308 [1.063-1.609]), high-density lipoprotein cholesterol (HDL-C) (1.243 [1.155-1.338]) and triglyceride (1.168 [1.076-1.268]), respectively.

CONCLUSIONS

In newly-diagnosed type 2 diabetes patients, higher remnant-C is independently associated with CKD incidence, even when conventional lipid values are well-controlled.

Acute worsening of microvascular complications of diabetes mellitus during rapid glycemic control: The pathobiology and therapeutic implications

While chronic hyperglycaemia resulting from poorly controlled diabetes mellitus (DM) is a well-known precursor to complications such as diabetic retinopathy, neuropathy (including autonomic neuropathy), and nephropathy, a paradoxical intensification of these complications can rarely occur with aggressive glycemic management resulting in a rapid reduction of glycated haemoglobin. Although, acute onset or worsening of retinopathy and treatment induced neuropathy of diabetes are more common among these complications, rarely other problems such as albuminuria, diabetic kidney disease, Charcot's neuroarthropathy, gastroparesis, and urinary bladder dysfunction are also encountered. The World Journal of Diabetes recently published a rare case of all these complications, occurring in a young type 1 diabetic female intensely managed during pregnancy, as a case report by Huret et al. It is essential to have a comprehensive understanding of the pathobiology, prevalence, predisposing factors, and management strategies for acute onset, or worsening of microvascular complications when rapid glycemic control is achieved, which serves to alleviate patient morbidity, enhance disease management compliance, and possibly to avoid medico-legal issues around this rare clinical problem. This editorial delves into the dynamics surrounding the acute exacerbation of microvascular complications in poorly controlled DM during rapid glycaemic control.

Predictors of microvascular complications in patients with type 2 diabetes mellitus at regional referral hospitals in the central zone, Tanzania: a cross-sectional study

Microvascular complications encompass a group of diseases which result from long-standing chronic effect of diabetes mellitus (DM). We aimed to determine the prevalence of microvascular complications and associated risk factors among patients with type 2 diabetes mellitus (T2DM). A cross-sectional analytical hospital-based study was conducted at Singida and Dodoma regional referral hospitals in Tanzania from December 2021 to September 2022. A total of 422 patients with T2DM were included in the analysis by determining the prevalence of microvascular complications and their predictors using multivariable logistic regression analysis. A two-tailed p value less than 0.05 was considered statistically significant. The prevalence of microvascular complications was 57.6% (n = 243) and diabetic retinopathy was the most common microvascular complication which accounted for 21.1% (n = 89). Having irregular physical activity (AOR = 7.27, 95% CI = 2.98-17.71, p < 0.001), never having physical activity (AOR = 2.38, 95% CI = 1.4-4.01, p = 0.013), being hypertensive (AOR = 5.0, 95% CI = 2.14-11.68, p = 0.030), having T2DM for more than 5 years (AOR = 2.74, 95% CI = 1.42-5.26, p = 0.025), being obese (AOR = 2.63, 95% CI = 1.22-5.68, p = 0.010), and taking anti-diabetic drugs irregularly (AOR = 1.94, 95% CI = 0.15-0.77, p < 0.001) were the predictors of microvascular complications. This study has revealed a significant proportion of microvascular complications in a cohort of patients with T2DM. Lack of regular physical activity, being obese, taking anti-diabetic drugs irregularly, presence of hypertension, and long-standing duration of the disease, were significantly associated with microvascular complications.

Effects of intensive glycemic control on microvascular outcomes in type 2 diabetes mellitus are modified by long-term HbA1c variability: A post hoc analysis of the ACCORD trial

AIMS

To assess the impact of long-term visit-to-visit variability in HbA1c on microvascular outcomes in type 2 diabetes mellitus (T2DM), and its influence on the effects of intensive glycemic control.

METHODS

Included were participants with T2DM enrolled in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) who had at least three measurements of HbA1c prior to new-onset microvascular outcomes, namely nephropathy, retinopathy and neuropathy. Variability in HbA1c was defined as the coefficient of variation (CV) across HbA1c measurements obtained from enrollment to the transition from intensive to standard glycemic therapy.

RESULTS

During a median of 22,005, 23,121, and 13,080 person-years of follow-up, 2,905 nephropathy, 2,655 retinopathy, and 1,974 neuropathy cases were recorded, respectively. Median CV (IQR) was 7.91 % (5.66 %-10.76 %) in the standard treatment group and 9.79 % (7.32 %-13.35 %) in the intensive treatment group. In the standard treatment group, lower HbA1c-CV (the first versus the second quartile) was associated with a higher risk of all microvascular outcomes, while higher HbA1c-CV (the fourth quartile) was associated with a higher risk of nephropathy only. In the intensive treatment group, only higher HbA1c-CV was associated with a higher risk of developing the microvascular outcomes. Intensive therapy reduced all microvascular outcomes among individuals with lower HbA1c-CV, but increased the risk among those with the highest HbA1c-CV (all P values for interaction < 0.0001). For example, hazard ratios (95 % CI) of retinopathy comparing intensive with standard treatments were 0.65 (0.56-0.75), 0.84 (0.71-0.98), 0.97 (0.82-1.14) and 1.28 (1.08-1.53) across the lowest to the highest quartiles of HbA1c variability.

CONCLUSIONS

The effects of intensive glycemic control on microvascular outcomes in T2DM appear to be modified by the variability of HbA1c during the treatment process, suggesting the significance of dynamic monitoring of HbA1c levels and timely adjustments to the therapeutic strategy among individuals with a high HbA1c variability.

Stem cells as a regenerative medicine approach in treatment of microvascular diabetic complications

Diabetes mellitus (DM) is a chronic metabolic disorder characterized by high blood glucose and is associated with high morbidity and mortality among the diabetic population. Uncontrolled chronic hyperglycaemia causes increased formation and accumulation of different oxidative and nitrosative stress markers, resulting in microvascular and macrovascular complications, which might seriously affect the quality of a patient's life. Conventional treatment strategies are confined to controlling blood glucose by regulating the insulin level and are not involved in attenuating the life-threatening complications of diabetes mellitus. Thus, there is an unmet need to develop a viable treatment strategy that could target the multi-etiological factors involved in the pathogenesis of diabetic complications. Stem cell therapy, a regenerative medicine approach, has been investigated in diabetic complications owing to their unique characteristic features of self-renewal, multilineage differentiation and regeneration potential. The present review is focused on potential therapeutic applications of stem cells in the treatment of microvascular diabetic complications such as nephropathy, retinopathy, and polyneuropathy.

Urine ACR uptake in patients with a diagnosis of type 1 and 2 diabetes mellitus in a primary care setting: A cross sectional study

BACKGROUND AND OBJECTIVES

A recent change in the diabetes Quality and Outcomes Framework (QOF) retired the mandatory testing of urinary ACR. We designed a study demonstrates the impact of this change in a primary healthcare setting. This is relevant as a significant proportion of the NHS budget is spent on managing microvascular and macrovascular complications that result from type 1 and 2 Diabetes mellitus.

METHODS

Our cross-sectional study collected testing data for 482 patients in a primary care setting. Based on the results seen from the first set of data collection, an intervention was offered to the clinicians by way of clinical presentation that emphasised and refreshed the knowledge of the latest NICE guidelines on urine ACR collection. Subsequently, a second set of data collection was conducted to assess the success, if any, of changes implemented based on the intervention made RESULTS: Our study demonstrates the drastic decrease in uptake of ACR testing in the primary care setting that took place following the change in the diabetes QOF.

CONCLUSION

The study highlights the need for the reintroduction of such a QOF measure to enable regular monitoring of early signs of nephropathy, thereby allow the timely commencement treatment as deemed appropriate. Furthermore, detecting the development of such complications in diabetic patients, in a timely manner, has the potential to reduce the financial footprint associated with treating the complications resulting from this condition.

Diabetic microvascular disease in non-classical beds: the hidden impact beyond the retina, the kidney, and the peripheral nerves

Diabetes microangiopathy, a hallmark complication of diabetes, is characterised by structural and functional abnormalities within the intricate network of microvessels beyond well-known and documented target organs, i.e., the retina, kidney, and peripheral nerves. Indeed, an intact microvascular bed is crucial for preserving each organ's specific functions and achieving physiological balance to meet their respective metabolic demands. Therefore, diabetes-related microvascular dysfunction leads to widespread multiorgan consequences in still-overlooked non-traditional target organs such as the brain, the lung, the bone tissue, the skin, the arterial wall, the heart, or the musculoskeletal system. All these organs are vulnerable to the physiopathological mechanisms that cause microvascular damage in diabetes (i.e., hyperglycaemia-induced oxidative stress, inflammation, and endothelial dysfunction) and collectively contribute to abnormalities in the microvessels' structure and function, compromising blood flow and tissue perfusion. However, the microcirculatory networks differ between organs due to variations in haemodynamic, vascular architecture, and affected cells, resulting in a spectrum of clinical presentations. The aim of this review is to focus on the multifaceted nature of microvascular impairment in diabetes through available evidence of specific consequences in often overlooked organs. A better understanding of diabetes microangiopathy in non-target organs provides a broader perspective on the systemic nature of the disease, underscoring the importance of recognising the comprehensive range of complications beyond the classic target sites.

Association Between Continuous Glucose Monitoring-Derived Glycemia Risk Index and Albuminuria in Type 2 Diabetes

Background: The glycemia risk index (GRI) is a new composite metric derived from continuous glucose monitoring (CGM) data to assess the quality of glycemia. This study investigates the association between the GRI and albuminuria. Methods: Professional CGM and urinary albumin-to-creatinine ratio (UACR) data from 866 individuals with type 2 diabetes were retrospectively reviewed. Albuminuria and macroalbuminuria were defined as one or more UACR measurements ≥30 and ≥300 mg/g, respectively. Results: The overall prevalence of albuminuria and macroalbuminuria was 36.6% and 13.9%, respectively. Participants with a higher UACR had a significantly higher hyperglycemia component and GRI score than those with a lower UACR (all P < 0.001), although the hypoglycemia component did not differ among the groups. Multiple logistic regression analyses that adjusted for various factors affecting albuminuria revealed that the odds ratio (OR) of albuminuria was 1.13 (95% confidence interval [CI]: 1.02-1.27, P = 0.039) per increase in the GRI zone. The results were similar for the risk of macroalbuminuria (OR: 1.42 [95% CI: 1.20-1.69], P < 0.001), and that association remained after adjusting for glycated hemoglobin (OR: 1.31 [95% CI: 1.10-1.58], P = 0.004). Conclusions: GRI is strongly associated with albuminuria, especially macroalbuminuria, in type 2 diabetes.

extract

Pterocarpus erinaceus Poir. from Fabaceae family is a medicinal plant traditionally used in decoction or infusion to treat diabetes mellitus. Although this plant is used in treating diabetes, studies on the effectiveness of its stem bark on the complications induced by chronic hyperglycemia have not been thoroughly addressed. Thus, this study was conducted to prove the efficacy of hydroethanolic extract of stem bark of P. erinaceus on type 2 diabetes and its complications, such as renal fibrosis and retinopathy in rats. STZ diabetics. The dry extract of P. erinaceus stem bark was obtained following the hydroethanolic extraction (v/v). Diabetes was induced with streptozocin in SD rats pretreated with fructose-lard for 20 days. Then, the serum and urinary biochemical parameters were evaluated at the start and the end of the treatment. Rats with blood glucose ≥350 mg/dL and significant proteinuria were selected and treated with P. erinaceus stem bark extract and glibenclamide for 3 weeks. A complete blood count and a histopathological examination of the retina and kidneys were performed at the end of the 41st day of treatment. The results showed that P. erinaceus extract at a dose of 500 mg/kg bw and glibenclamide at a dose of 0.6 mg/kg bw caused a significant decrease (p < 0.0001) in basal blood glucose in STZ diabetic rats during treatment and improved oral glucose intolerance. At the end of the experiment, the treated rats showed a normalization in body weight, food and water consumption. Evaluating of biochemical parameters showed a significant (p < 0.001) decrease in total cholesterol, LDL-C, triglycerides, TG/HDL-C ratio, CPK and oxidative stress in treated rats. No retinal and kidney abnormalities were observed on histological sections in rats treated with plant extract and glibenclamide. In contrast, macular edema and renal fibrosis were observed in the diabetic control group. The findings showed that extract at a dose of 500 mg/kg bw improves oral glucose intolerance, and inhibits lipid deposition and retinal and renal fibrosis. Therefore, the plant extract could be exploited in the production of herbal medicines to manage diabetes and its complications.

Macrovascular and renal microvascular complications in West Africans with intermediate hyperglycemia living in West Africa and Europe: The RODAM study

Background

Metabolic conditions, including intermediate hyperglycemia (IH), affect migrants to a greater extent than the populations of origin. Evidence suggests that IH increases the risk of vascular complications, but it is unclear whether the differences in IH between the non-migrant and migrant populations translate to differences in vascular complications between the two populations. We compared the prevalence of macrovascular and renal microvascular complications among West Africans with IH living in West Africa and their migrant compatriots in Europe.

Methods

Data from the multicenter Research on Obesity and Diabetes among African Migrants(RODAM) study were analyzed. Ghanaians with IH(524 non-migrant and 1439 migrants) were included. Logistic regression analyses were used to determine the associations between migrant status and macrovascular [coronary artery disease(CAD) and peripheral artery disease(PAD)] and renal microvascular[nephropathy] complications with adjustment for age, sex, socioeconomic status, smoking, systolic blood pressure, BMI, total cholesterol, HbA1c, C-reactive protein, and serum uric acid.

Findings

The prevalence of microvascular/macrovascular complications was higher in non-migrants than in migrants(nephropathy 15.3vs.9.7%; PAD 3.1%vs.1.3%; and CAD 15.8% vs. 5.0%). The differences persisted in the fully adjusted model: nephropathy [odds ratio, 2.12; 95% CI(1.46-3.08); PAD, 4.44(1.87-10.51); CAD 2.35(1.64-3.37)]. Non-migrant females had higher odds of nephropathy[2.14(1.34-3.43)], PAD[7.47(2.38-23.40)] and CAD [2.10(1.34-3.27)] compared to migrant females. Non-migrant males had higher odds of nephropathy[2.54(1.30-4.97)] and CAD[2.85(1.48-5.50)], but not PAD[1.81(0.32-10.29)],than their migrant peers.

Interpretation

Macrovascular and renal microvascular complications were more prevalent in non-migrants than in migrant West Africans with IH. Further studies are needed to identify factors that increase the risk to aid preventive/treatment strategies.

Benefits of bariatric surgery on microvascular outcomes in adult patients with type 2 diabetes: a systematic review and meta-analysis

BACKGROUND

Microvascular diabetes complications impair patients' health-related quality of life. Bariatric surgery (BS) emerged as a compelling treatment that demonstrated to have beneficial effects on patients with diabetes and obesity.

OBJECTIVE

We aimed to synthesize the benefit of bariatric surgery on microvascular outcomes in adult patients with type 2 diabetes.

SETTING

2011-2021.

METHODS

We included both cohort studies and randomized trials that evaluated bariatric surgery added to medical therapy compared with medical therapy alone in the treatment of adult patients with type 2 diabetes. Studies must have evaluated the incidence of any microvascular complication of the disease for a period of at least 6 months. We performed our search using PubMed, Scopus, EMBASE, Web of Science, and COCHRANE Central database which was performed from inception date until March 2021. PROSPERO (CRD42021243739).

RESULTS

A total of 25 studies (160,072 participants) were included. Pooled analysis revealed bariatric surgery to reduce the incidence of any stage of retinopathy by 71% (odds ratio [OR] .29; 95% confidence interval [CI] .10-.91), nephropathy incidence by 59% (OR .41; 95% CI 17-96), and hemodialysis/end-stage renal disease by 69% (OR .31 95% CI .20-.48). Neuropathy incidence revealed no difference between groups (OR .11; 95% CI .01-1.37). Bariatric surgery increased the odds of albuminuria regression by 15.15 (95% CI 5.96-38.52); higher odds of retinopathy regression were not observed (OR 3.73; 95% CI .29-47.71). There were no statistically significant differences between groups regarding the change in surrogate outcomes.

CONCLUSIONS

Bariatric surgery in adult patients with diabetes reduced the odds of any stage of retinopathy, hemodialysis/end-stage renal disease, and nephropathy composite outcome. However, its effect on many individual outcomes, both surrogates, and clinically significant, remains uncertain.

THE IMPACT OF TOTAL PHYSICAL ACTIVITY ON MICROVASCULAR COMPLICATIONS IN TYPE 1 DIABETES MELLITUS PATIENTS

The incidence of diabetes is increasing worldwide, emphasizing an emerging need for blood glucose control optimization to prevent the development of chronic complications and improve the quality of life. This retrospective cohort study aimed to investigate the effects of total physical activity on microvascular diabetic complication development in patients with type 1 diabetes mellitus (T1DM). The study included 71 T1DM patients, average age 41 years and HbA1c 7.78%. Most patients (82.1%) reported having hypoglycemia, while the minority of patients developed microvascular complications, mostly nonproliferative retinopathy (17.7%). All subjects included in the study were moderately or vigorously physically active. No association was observed between total physical activity and regulation of glycemia, hypoglycemic incidents, or development of microvascular complications. Until sufficient data from prospective studies become available, our data support the findings of no negative effect of higher intensity physical activity on the development of microvascular complications in T1DM patients.

Diabetes in a hospital cohort of persons living with HIV: a descriptive and comparative study in French Guiana

BACKGROUND

In French Guiana (population 294,000) the prevalence of type 2 diabetes (10%) and of HIV(1.1%) are very high. Our objective was to determine the prevalence of diabetes and its complications in a HIV cohort.

MATERIALS AND METHODS

We enrolled HIV-infected persons followed in Cayenne, Kourou, and Saint Laurent du Maroni hospitals between January 1, 1992 and December 31, 2021 in the French Hospital Database for HIV (FHDH) a national database compiling data from all French regions.

RESULTS

There was no difference of diabetes prevalence between men (8.2%) and women (8.8%), P = 0.4. Patients with diabetes were older (56 years ± 13.4) than those without diabetes (44.7 years ± 13.6) and prevalence increased with age. The proportion of persons with diabetes was greater among virologically suppressed persons (10%) than those with a detectable viral load under antiretroviral treatment (5.8%). Persons with diabetes had substantially greater CD4 counts at diagnosis than persons without diabetes. The majority of macro and microvascular complications were observed in people with diabetes. Persons with diabetes and HIV were significantly less likely to have had AIDS (1.6 versus 2.2 per 100 person-years, respectively). Overall, 374 persons living with HIV of 4167 had died (9%) the proportion of persons with diabetes among the dead was greater than those who did not die 11.7% versus 8.1%, respectively, p = 0.017. However, persons with diabetes were older and hence died older, 62.3 years (SD = 1.9) for deceased persons with diabetes versus 50.4 years (SD = 0.8), P < 0.0001. However, using Cox regression to adjust for age, initial CD4 count, country of birth there was no significant difference in the Hazard for death between persons with diabetes and persons without diabetes (aHR = 0.99, 95%CI = 0.65-1.5), P = 0.9.

CONCLUSIONS

The prevalence of diabetes in our HIV cohort was high. Persons with diabetes had greater CD4 counts, earlier care, and greater virological suppression than persons without diabetes. There were no significant differences between persons with diabetes and without diabetes in terms of survival.

Both LDL and HDL particle concentrations associate positively with an increased risk of developing microvascular complications in patients with type 2 diabetes: lost protection by HDL (Zodiac-63)

BACKGROUND

Triglyceride-rich lipoproteins (TRL) and low-density lipoproteins (LDL) are associated positively whereas high-density lipoproteins (HDL) are associated inversely with the development of new-onset type 2 diabetes (T2D). Here we studied potential associations between these lipoprotein particle concentrations and the risk of developing microvascular complications in patients with established T2D.

METHODS

Lipoprotein particle concentrations (TRLP, LDLP, and HDLP) were determined in 278 patients with T2D participating in a primary care-based longitudinal cohort study (Zwolle Outpatient Diabetes project Integrating Available Care [ZODIAC] study) leveraging the Vantera nuclear magnetic resonance (NMR) platform using the LP4 algorithm. Associations between lipoprotein particles and incident microvascular complications (nephropathy, neuropathy, and retinopathy) were assessed using Cox proportional hazards regression models.

RESULTS

In total, 136 patients had microvascular complications at baseline. During a median follow-up of 3.2 years, 49 (34.5%) of 142 patients without microvascular complications at baseline developed new-onset microvascular complications. In multivariable Cox proportional hazards regression analyses, both total LDLP and HDLP concentrations, but not total TRLP concentrations, were positively associated with an increased risk of developing any microvascular complications after adjustment for potential confounding factors, including age, sex, disease duration, HbA1c levels, history of macrovascular complications, and statin use (adjusted hazard ratio [HR] per 1 SD increment: 1.70 [95% CI 1.24-2.34], P < 0.001 and 1.63 [95% CI 1.19-2.23], P = 0.002, respectively). When analyzing each microvascular complication individually, total LDLP concentrations were positively associated with retinopathy (adjusted HR 3.35, 95% CI 1.35-8.30, P = 0.009) and nephropathy (adjusted HR 2.13, 95% CI 1.27-3.35, P = 0.004), and total HDLP concentrations with neuropathy (adjusted HR 1.77, 95% CI 1.15-2.70, P = 0.009). No significant associations were observed for lipoprotein particle subfractions.

CONCLUSIONS

Total lipoprotein particle concentrations of both LDL and HDL associate positively with an increased risk of developing microvascular complications in T2D. We propose that the protective role of HDL on the development of microvascular complications may be lost in established T2D.

Update on Medical Management of Diabetes: Focus on Relevance for Orthopedic Surgeons

Diabetes mellitus affects more than 30 million US adults and 537 million people worldwide and accounts for major complications, including more than 100,000 lower extremity amputations annually in the United States. Peripheral neuropathy, peripheral vascular disease, and foot ulcers are frequent findings in diabetes patients at risk for amputation. Suboptimal care of early foot lesions increases the risk of amputation. Studies have shown that these complications can be prevented in people with type 1 and type 2 diabetes by optimizing glycemic control and comorbid risk factors. This review focuses on evaluating and managing diabetes, which should interest orthopedic surgeons.

Evaluation of the expression levels of lncRNAs H19 and MEG3 in patients with type 2 diabetes mellitus

BACKGROUND

LncRNAs may play a role in either suppressing or exacerbating diabetes-associated vascular complications.

AIMS

This study aimed to assess MEG3 and H19 expression levels in T2DM and pre-diabetes and their roles in diabetes-related microvascular complications.

SUBJECT AND METHODS

(RT-PCR) analysis of the MEG3 and H19 plasma levels was carried out in 180 participants of T2DM, pre-diabetes, and control.

RESULTS

The expression level of lncRNA H19 was significantly down-regulated and lncRNA MEG3 up-regulated in T2DM compared to pre-diabetes and control, also for pre-diabetes versus control. The (ROC) analysis of MEG3 and H19 relative expression levels showed that MEG3 has better sensitivity for distinguishing T2DM from pre-diabetes and control groups.In comparison, H19 offered superior sensitivity to distinguish pre-diabetic from controls. Additionally, H19 was reported as an independent risk factor for T2DM by multivariate analysis. Low expression of H19 and over-expressed MEG3 were significantly associated with retinopathy, nephropathy, and elevated renal indicators (urea, creatinine, and UACR.

CONCLUSION

Our results implicated the potential diagnostic and predictive roles of lncRNA MEG3 and H19 for T2DM and related microvascular complications. Additionally, H19 may serve as a potential biomarker for pre-diabetes prediction.

Metabolic syndrome in patients with type 1 diabetes mellitus at a tertiary centre in North India: A five year follow up study

BACKGROUND AND AIMS

Metabolic syndrome (MS) is prevalent in the Indian population and has been traditionally linked to Type 2 diabetes mellitus (T2DM). Its presence is now being increasingly recognized in patients with Type 1 diabetes mellitus (T1DM). Presence of MS may increase the risk of diabetes related complications. This study was designed to determine the prevalence of MS in a cohort of patients with T1DM at baseline and at 5 years of follow up.

METHODS

Longitudinal cohort study in a tertiary care center in North India. Patients with T1DM attending the Diabetes of the Young (DOY) Clinic from January 2015 to March 2016 included. Microvascular and macrovascular complications assessed. The cohort was followed after a period of 5 years.

RESULTS

We included 161 patients (males, 49.4%) with a median (IQR) age of 23 (18-34) years and median (IQR) diabetes duration of 12 (7, 17) years. At baseline, 31 (19.2%) patients had MS. Patients with MS were more likely to have microvascular complications: retinopathy (p = 0.003), neuropathy (p = 0.02) and nephropathy (p = 0.04). Independent predictors of MS: insulin sensitivity (IS) (adjusted OR (aOR) 0.02 [95% CI, 0.003-0.118]), body weight (aOR 1.05 [95% CI, 1.007-1.108]), diastolic blood pressure (aOR 1.08 [95% CI, 1.01-1.15]) and duration of diabetes (aOR 1.09 [95% CI, 1.02-1.16]). On follow-up (n = 100), 13 (13%) had MS.

CONCLUSIONS

One in 5 patients with T1DM suffers from MS, and is therefore predisposed to its attendant risks, calling for early identification and targeted interventions.

Association between brachial-ankle pulse wave velocity and microvascular complications in type 2 diabetes mellitus

PURPOSE/AIM

To investigate the relationship between brachial-ankle pulse wave velocity (baPWV) and microvascular complications in type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

From 2019 to 2021, our hospital enrolled 322 patients with T2DM. Clinical information and biochemical indicators of patients were collected from the inpatient electronic medical record system and analyzed retrospectively. Fundus photography, nerve conduction testing, and sensory threshold measurement were all conducted on the subjects. We measured the pulse wave velocity on both sides of the arm and ankle, then averaged the results. The enrolled cases were divided into two groups based on the baPWV: Group 1 (<the reference cutoff value, n = 160) and Group 2 (≥ the reference cutoff value, n = 162). The association between associated factors and baPWV abnormalities was investigated using a logistic regression model.

RESULTS

Group 2 had higher Systolic Blood Pressure(SBP), Diastolic Blood Pressure (DBP), duration of diabetes, Fasting Plasma Glucose (FPG), Blood Urea Nitrogen (BUN) and Serum Uric Acid (SUA) than group 1 (all p < 0.05). The prevalence of diabetic retinopathy, peripheral neuropathy and nephropathy in group 2 was higher compared to group 1 (p < 0.05). After classifying subjects according to the presence or absence of diabetic complications, we found that the baPWV of the Diabetic Peripheral Neuropathy (DPN) group and Diabetic Nephropathy (DN) group was noticeably higher than that of non-DPN group and non-DN group, respectively (both p < 0.05). The baPWV increased with the aggravation of Diabetic Retinopathy (DR) (p < 0.05). Multivariate logistic regression analysis showed that DBP (OR 1.039, 95%CI 1.010-1.068 p = 0.008), duration of diabetes (OR 1.059, 95%CI 1.017-1.103 p = 0.006), FPG (OR 1.104, 95%CI 1.025-1.188 p = 0.009) and BUN (OR 1.128, 95%CI 1.001-1.270 p = 0.048) were all independently and positively associated with baPWV.

CONCLUSIONS

The baPWV is strongly associated with microvascular complications of T2DM. The DBP, duration of diabetes, FPG, and BUN were all independent associated factors of baPWV.

Semaglutide-eye-catching results

Semaglutide is a glucagon-like peptide-1 receptor agonist used either orally every day or subcutaneously once a week for the treatment of type 2 diabetes mellitus and, more recently, at higher doses, for the treatment of obesity. Both diseases are reaching epidemic proportions and often coexist, posing patients with a high risk for cardiovascular disease and death. Therefore, an agent such as semaglutide, which offers clinically significant weight loss and cardiovascular benefits, is essential and will be increasingly used in high-risk patients. However, during the SUSTAIN clinical trial program (Semaglutide Unabated Sustainability in treat-ment of type 2 diabetes), a safety issue concerning the progression and worsening of diabetic retinopathy emerged. The existing explanation so far mainly supports the role of the magnitude and speed of HbA1c reduction, a phenomenon also associated with insulin treatment and bariatric surgery. Whether and to which extent the effect is direct is still a matter of debate and an intriguing topic to investigate for suitable preventative and rehabilitative purposes. In this minireview, we will summarize the available data and suggest guidelines for a comprehensive semaglutide clinical utilization until new evidence becomes available.

Impact of microvascular complications on the outcomes of diabetic foot in type 2 diabetic patients with documented peripheral artery disease

PURPOSE

Microvascular disease (MVD) is associated with amputation linked to peripheral artery disease (PAD) in the general population. No study evaluated the impact of diabetic microvascular complications on the outcomes of vascular diabetic foot ulcers (DFU). The aim of the study was to investigate whether retinopathy, nephropathy, and polyneuropathy can predict the outcomes of DFU in type 2 diabetic patients with PAD.

METHODS

Three hundred and thirty-one consecutive patients with vascular DFU were enrolled and followed up for 44.1 ± 23.9 months.

RESULTS

The prevalence of retinopathy was significantly higher in subjects with ulcer persistence (45.2%; p < 0.01), minor amputation (48.9%; p < 0.001), and major amputation (57.9%; p < 0.001) than in healed patients (23.3%), and in non-survivors than in survivors (64.9 versus 20.5%; p < 0.001). The prevalence of nephropathy was significantly greater in subjects with ulcer persistence (83.9%; p < 0.01), minor amputation (86.7%; p < 0.001), and major amputation (94.7%; p < 0.001) than in those with healed DFU (64.4%), and in non-survivors than in survivors (88.3 versus 65.7%; p < 0.001). The prevalence of polyneuropathy was significantly higher in non-survivors than in survivors (76.6 versus 61.0%; p = 0.012). Multivariate analysis showed that absence of retinopathy (OR: 0.451; 95% CI: 0.250-0.815; p < 0.001) and nephropathy (OR: 0.450; 95% CI: 0.212-0.951; p = 0.036) were independently associated with healing. Moreover, retinopathy was a predictor both of minor amputation (OR: 2.291; 95% CI: 1.061-4.949; p = 0.034) and mortality (OR: 5.274; 95% CI: 2.524-11.020; p < 0.001). Polyneuropathy never entered the regression model.

CONCLUSIONS

Diabetic microvascular complications, in particular retinopathy, may predict the outcomes of vascular DFU. Longitudinal studies should confirm this finding.

Weight variability and diabetes complications

Body weight is a recognized risk factor for cardiovascular diseases (CVD). More recently, weight variability, i.e. the oscillation of body weight over time, has also been suggested to be independently associated with development of CVD and mortality in subjects without diabetes and in people with both type 1 and type 2 diabetes (T2D). In T2D, weight variability emerged as one of the most relevant risk factors for CVD and it was suggested to interact with the variability of other risk factors to identify people at high cardiovascular risk. In addition, weight variability seems also to confer a higher risk for microvascular complications in people with T2D. While the exact mechanism linking weight variability to CVD is unknown, evidence from experimental models suggests that weight cycling promote an enduring pro-inflammatory program in the adipose tissue. Here we review the clinical evidence relative to the association of weight variability with CVD and microvascular complications of diabetes. We then briefly summarize the alterations proposed to explain this association. Finally, we synthesize the possible strategies, e.g. specific dietetic regimens and available glucose-lowering drugs, to minimize weight fluctuations.

Residual β-cell function in Brazilian Type 1 diabetes after 3 years of diagnosis: prevalence and association with low presence of nephropathy

BACKGROUND

Persistence of β cell-function in Type 1 diabetes (T1D) is associated with glycaemia stability and lower prevalence of microvascular complications. We aimed to assess the prevalence of residual C- peptide secretion in long-term Brazilian childhood onset T1D receiving usual diabetes care and its association to clinical, metabolic variables and microvascular complications.

METHODS

A cross-sectional observational study with 138 T1D adults with ≥ 3 years from the diagnosis by routine diabetes care. Clinical, metabolic variables and microvascular complications were compared between positive ultra-sensitive fasting serum C-peptide (FCP +) and negative (FCP-) participants.

RESULTS

T1D studied had ≥ 3 yrs. of diagnosis and 60% had FCP > 1.15 pmol/L. FCP + T1D were older at diagnosis (10 vs 8 y.o; p = 0.03) and had less duration of diabetes (11 vs 15 y.o; p = 0.002). There was no association between the FCP + and other clinical and metabolic variable but there was inversely association with microalbuminuria (28.6% vs 13.4%, p = 0.03), regardless of HbA_1c. FCP > 47 pmol/L were associated with nephropathy protection but were not related to others microvascular complications.

CONCLUSION

Residual insulin secretion is present in 60% of T1D with ≥ 3 years of diagnosis in routine diabetes care. FCP + was positively associated with age of diagnosis and negatively with duration of disease and microalbuminuria, regardless of HbA_1c.

Sex differences in type 2 diabetes

The prevalence of type 2 diabetes mellitus is increasing in both sexes, but men are usually diagnosed at a younger age and lower body fat mass than women. Worldwide, an estimated 17.7 million more men than women have diabetes mellitus. Women appear to bear a greater risk factor burden at the time of their type 2 diabetes diagnosis, especially obesity. Moreover, psychosocial stress might play a more prominent role in diabetes risk in women. Across their lifespan, women experience greater hormone fluctuations and body changes due to reproductive factors than men. Pregnancies can unmask pre-existing metabolic abnormalities, resulting in the diagnosis of gestational diabetes, which appears to be the most prominent risk factor for progression to type 2 diabetes in women. Additionally, menopause increases women's cardiometabolic risk profile. Due to the progressive rise in obesity, there is a global increase in women with pregestational type 2 diabetes, often with inadequate preconceptual care. There are differences between men and women regarding type 2 diabetes and other cardiovascular risk factors with respect to comorbidities, the manifestation of complications and the initiation of and adherence to therapy. Women with type 2 diabetes show greater relative risk of CVD and mortality than men. Moreover, young women with type 2 diabetes are currently less likely than men to receive the treatment and CVD risk reduction recommended by guidelines. Current medical recommendations do not provide information on sex-specific or gender-sensitive prevention strategies and management. Thus, more research on sex differences, including the underlying mechanisms, is necessary to increase the evidence in the future. Nonetheless, intensified efforts to screen for glucose metabolism disorders and other cardiovascular risk factors, as well as the early establishment of prophylactic measures and aggressive risk management strategies, are still required for both men and women at increased risk of type 2 diabetes. In this narrative review we aim to summarise sex-specific clinical features and differences between women and men with type 2 diabetes into risk factors, screening, diagnosis, complications and treatment.

Developing community pharmacists' role in the management of type 2 diabetes and related microvascular complications: a nationwide survey in Australia

Background

Community pharmacists have regular interactions with people living with type 2 diabetes to supply medications, and have a potential role in supporting other primary care professionals in the screening, management, monitoring and facilitation of timely referral of microvascular complications. This study aimed to investigate the contemporary and future roles of community pharmacists in diabetes-related microvascular complication management.

Methods

This study involved an online Australian nation-wide survey of pharmacists administered via Qualtrics® and distributed through social media platforms, state and national pharmacy organisations, and via major banner groups. Descriptive analyses were undertaken using SPSS.

Results

Among 77 valid responses, 72% of pharmacists already provided blood pressure and blood glucose monitoring services for the management of type 2 diabetes. Only 14% reported providing specific microvascular complication services. Over 80% identified a need for a comprehensive microvascular complication monitoring and referral service, and agreed it is feasible and within the scope of practice of a pharmacist. Almost all respondents agreed that they would implement and provide a monitoring and referral service if provided with appropriate training and resources. Potential barriers to service implementation were competing demands and lack of remuneration and awareness among consumers and health professionals.

Conclusions

Type 2 diabetes services in Australian community pharmacies do not currently focus on microvascular complication management. There appears to be strong support for implementing a novel screening, monitoring and referral service via community pharmacy to facilitate timely access to care. Successful implementation would require additional pharmacist training, and identification of efficient pathways for service integration and remuneration.

Plasma levels of GlycA, a pro-inflammatory glycoprotein biomarker, associate with an increased risk of microvascular complications in patients with type 2 diabetes (Zodiac-62)

PURPOSE

GlycA, a pro-inflammatory glycoprotein biomarker, associates with newly developed type 2 diabetes (T2D). We determined the association of plasma GlycA with the development of microvascular complications in patients with established T2D.

METHODS

Plasma GlycA was measured by nuclear magnetic resonance spectrometry in T2D patients without microvascular complications at baseline (n = 145) participating in a longitudinal cohort study of primary care-treated T2D patients (Zwolle Outpatient Diabetes project Integrating Available Care (ZODIAC) study). Associations of GlycA with incident microvascular complications including nephropathy, retinopathy, and neuropathy, were determined by Cox proportional hazards regression analyses.

RESULTS

After a median follow-up of 3.2 (interquartile range [IQR]: 2.9-3.4) years, 49 patients (33.8%) developed one or more microvascular complications. Median GlycA levels were 453.5 (IQR: 402.0-512.8) μmol/l. GlycA was associated with incident microvascular complications (hazard ratio [HR] per 1-SD increment: 1.28 [95% confidence interval [CI]:1.00-1.63], P = 0.048]), even after adjustment for potential confounders and high-sensitive C-reactive protein (hs-CRP), HR 1.79 [95%CI:1.25-2.57], P = 0.001). In contrast, hs-CRP levels were not significantly associated with the risk of developing microvascular complications (P = 0.792).

CONCLUSION

Higher plasma GlycA is associated with an increased risk of developing microvascular complications in T2D patients. Altered N-glycan branching associated with acute-phase reactive proteins may represent a preferred biomarker of systemic low-grade inflammation in predicting diabetic complications.

Diabetic microvascular complications predicts non-heart failure with reduced ejection fraction in type 2 diabetes

AIMS

The relationship between diabetic microvascular complications and the incidence of two types of heart failure-heart failure with reduced ejection fraction (HFrEF) (left ventricular ejection fraction [LVEF] < 40%) and non-HFrEF (LVEF ≥ 40%)-in patients without prior heart failure has not been clarified. We herein examined the association between diabetic microvascular complications and HFrEF or non-HFrEF in patients with type 2 diabetes mellitus (T2DM) without prior heart failure.

METHODS AND RESULTS

In this retrospective cohort study, we assessed the relationship between the presence of diabetic microvascular complications or severity of diabetic retinopathy (no apparent, non-proliferative and proliferative retinopathy) and nephropathy (normoalbuminuria, microalbuminuria, and macroalbuminuria) at baseline, with the primary outcome of first heart failure hospitalization classified as HFrEF or non-HFrEF in patients with type 2 diabetes mellitus without prior heart failure. Among 568 patients (69.2% males, mean age 66.2 ± 9.6 years), 70 experienced heart failure hospitalization (HFrEF: 24 and non-HFrEF: 46). Non-HFrEF hospitalization but not HFrEF hospitalization was significantly associated with the presence of diabetic microvascular complications. The incidence of non-HFrEF hospitalization was significantly higher in the proliferative retinopathy group than that in the no apparent retinopathy group (adjusted hazard ratio [HR] 2.96, 95% confidence interval [CI]: 1.09-6.83, P = 0.035) and in those with macroalbuminuria than in those with normoalbuminuria (adjusted HR 4.23, 95% CI: 2.24-7.85, P < 0.001) even after adjustment for age and sex. When non-HFrEF was classified into heart failure with mildly reduced ejection fraction (HFmrEF) (40% ≤ LVEF < 50%) and heart failure with preserved ejection fraction (HFpEF) (50% ≤ LVEF), HFmrEF and HFpEF hospitalizations were also found to be associated with the progression of retinopathy and nephropathy.

CONCLUSIONS

In patients with T2DM without prior heart failure, non-HFrEF hospitalization was more closely associated with the progression of diabetic microangiopathy than HFrEF. The development of non-HFrEF may be mediated through a mechanism similar to that of microvascular complications in these patients.

Identification of genetic variants associated with diabetic kidney disease in multiple Korean cohorts via a genome-wide association study mega-analysis

BACKGROUND

The pathogenesis of diabetic kidney disease (DKD) is complex, involving metabolic and hemodynamic factors. Although DKD has been established as a heritable disorder and several genetic studies have been conducted, the identification of unique genetic variants for DKD is limited by its multiplex classification based on the phenotypes of diabetes mellitus (DM) and chronic kidney disease (CKD). Thus, we aimed to identify the genetic variants related to DKD that differentiate it from type 2 DM and CKD.

METHODS

We conducted a large-scale genome-wide association study mega-analysis, combining Korean multi-cohorts using multinomial logistic regression. A total of 33,879 patients were classified into four groups-normal, DM without CKD, CKD without DM, and DKD-and were further analyzed to identify novel single-nucleotide polymorphisms (SNPs) associated with DKD. Additionally, fine-mapping analysis was conducted to investigate whether the variants of interest contribute to a trait. Conditional analyses adjusting for the effect of type 1 DM (T1D)-associated HLA variants were also performed to remove confounding factors of genetic association with T1D. Moreover, analysis of expression quantitative trait loci (eQTL) was performed using the Genotype-Tissue Expression project. Differentially expressed genes (DEGs) were analyzed using the Gene Expression Omnibus database (GSE30529). The significant eQTL DEGs were used to explore the predicted interaction networks using search tools for the retrieval of interacting genes and proteins.

RESULTS

We identified three novel SNPs [rs3128852 (P = 8.21×10^-25), rs117744700 (P = 8.28×10^-10), and rs28366355 (P = 2.04×10^-8)] associated with DKD. Moreover, the fine-mapping study validated the causal relationship between rs3128852 and DKD. rs3128852 is an eQTL for TRIM27 in whole blood tissues and HLA-A in adipose-subcutaneous tissues. rs28366355 is an eQTL for HLA-group genes present in most tissues.

CONCLUSIONS

We successfully identified SNPs (rs3128852, rs117744700, and rs28366355) associated with DKD and verified the causal association between rs3128852 and DKD. According to the in silico analysis, TRIM27 and HLA-A can define DKD pathophysiology and are associated with immune response and autophagy. However, further research is necessary to understand the mechanism of immunity and autophagy in the pathophysiology of DKD and to prevent and treat DKD.

miRNAs as cornerstones in diabetic microvascular complications

Diabetes mellitus is usually accompanied by nephropathy, retinopathy, and neuropathy as microvascular complications. MicroRNAs (miRNAs) can affect the kidney, retina, and peripheral neurons through their implication in pathways involved in angiogenesis, inflammation, apoptosis, as well as fibrosis within these tissues and hence, play a crucial role in the pathogenesis of microvascular complications. In this review, the updated knowledge of the role of miRNAs in the pathogenesis of diabetic microvascular complications was summarized. PubMed Central was searched extensively to retrieve data from a wide range of reputable biomedical reports/articles published after the year 2000 to systematically collect and present a review of the key molecular pathways mediating the hyperglycemia-induced adverse effects on vascular tissues, particularly in persons with T2DM. In the present review, miR-126, miR-29b, and miR-125a are implicated in diabetes-induced microvascular complications, while miR-146a is found to be connected to all these complications. Also, vascular endothelial growth factors are noted to be the most impacted targets by miRNAs in all diabetic microvascular problems.

Diabetic microvascular complications are associated with left atrial structural alterations in asymptomatic type 2 diabetes patients: A cross-sectional study

AIMS

We used 4D-Auto LAQ to quantitatively evaluate the morphological and functional changes of left atrium in patients with asymptomatic type 2 diabetes mellitus (T2DM), and explored its correlations with diabetic microvascular complications (MICRO).

METHODS

This study included 319 patients with asymptomatic T2DM. According to the occurrence of MICRO, these patients were divided into 3 groups: patients with no complication, 1 complication, and 2-3 complications. 4D-Auto LAQ was used to evaluate left atrial volume (LAVImin, LAVImax, LAVIpre) and calculate the left atrial function (DEI, PEI, AEI) in different phases. Multiple linear regression was used to analyze the correlation between changes in left atrial volume and function and the number of MICROs in DM patients.

RESULTS

A total of 279 patients with asymptomatic T2DM were included in this study. (1) The ultrasound data of the three T2DM groups showed that there was no significant difference in left ventricular size and function among the three groups; (2) with the increase of MICRO number, the left atrial volume (LAVImin, LAVImax, LAVIpre) progressively increased, the left atrial storage function index (DEI) gradually decreased, and the differences were significant (P < 0.05). (3) Multiple linear regression analysis showed that: with the increase of MICRO number (no complication→1 complication→2-3 complications), the left atrial volume (LAVImin, LAVIpre) showed an increasing trend (both P < 0.05).

CONCLUSION

In asymptomatic T2DM patients, MICRO number showed a significant positive correlation with LAVImin and LAVIpre (P < 0.05). Therefore, the increase in left atrial volume can dynamically reflect the severity of microvascular lesions in patients with asymptomatic T2DM.

Precision prognostics for the development of complications in diabetes

Individuals with diabetes face higher risks for macro- and microvascular complications than their non-diabetic counterparts. The concept of precision medicine in diabetes aims to optimise treatment decisions for individual patients to reduce the risk of major diabetic complications, including cardiovascular outcomes, retinopathy, nephropathy, neuropathy and overall mortality. In this context, prognostic models can be used to estimate an individual's risk for relevant complications based on individual risk profiles. This review aims to place the concept of prediction modelling into the context of precision prognostics. As opposed to identification of diabetes subsets, the development of prediction models, including the selection of predictors based on their longitudinal association with the outcome of interest and their discriminatory ability, allows estimation of an individual's absolute risk of complications. As a consequence, such models provide information about potential patient subgroups and their treatment needs. This review provides insight into the methodological issues specifically related to the development and validation of prediction models for diabetes complications. We summarise existing prediction models for macro- and microvascular complications, commonly included predictors, and examples of available validation studies. The review also discusses the potential of non-classical risk markers and omics-based predictors. Finally, it gives insight into the requirements and challenges related to the clinical applications and implementation of developed predictions models to optimise medical decision making.

Prevalence and risk of diabetic complications in young-onset versus late-onset type 2 diabetes mellitus

AIMS

To compare the prevalence and risk of diabetic complications between people with young-onset and late-onset type 2 diabetes mellitus (T2DM).

METHODS

In this observational study, 10,447 people with T2DM had at least one study of diabetic complications: retinopathy, neuropathy, chronic kidney disease (CKD), carotid artery plaque. We use odds ratios to compare complications between young-onset T2DM (YOD) and late-onset T2DM (LOD).

RESULTS

We compare 1,791 people with YOD (diagnosed < 40 years) and 8,656 with LOD (diagnosed ≥ 40 years). The YOD had a higher prevalence of these complications than the LOD (p < 0.011) after adjustment for confounding factors. Further adjustment for diabetes duration greatly attenuated the odds ratios however, neuropathy remained significantly more frequent in people with YOD (adjusted odds ratio: 1.39, 95% confidence interval: 1.13-1.71, p = 002). In cluster analysis on the 2,126 study participants who were diagnosed with T2DM within the previous two years, 47% of the YOD group were in the severe insulin-deficient diabetes cluster in comparison to 23% LOD; 28% and 44% respectively were in the mild age-related diabetes.

CONCLUSION

People with YOD had a higher prevalence of complications than those with LOD, but this was mostly attributed to a longer duration of diabetes. However, the prevalence of neuropathy remained significantly higher even after adjusting for factors including the duration of diabetes.

Registry-based randomised clinical trials: a remedy for evidence-based diabetes care?

This narrative review describes a new approach to navigation in a challenging landscape of clinical drug development in diabetes. Successful outcome studies in recent years have led to new indications and guidelines in type 2 diabetes, yet the number of clinical trials in diabetes is now declining. This is due to many environmental factors acting in concert, including the prioritisation of funding for other diseases, high costs of large randomised clinical trials, increase in regulatory requirements and limited entry of novel candidate drugs. There is a need for novel and cost-effective paradigms of clinical development to meet these and other challenges. The concept of registry-based randomised clinical trials (RRCTs) is an attractive option. In this review we focus on type 2 diabetes and the prevention of cardiovascular and microvascular comorbidities and mortality, using the Swedish SMARTEST trial as an example of an RRCT. We also give some examples from other disease areas. The RRCT concept is a novel, cost-effective and scientifically sound approach for conducting large-scale diabetes trials in a real-world setting.

The Risks of Cardiovascular Disease Following Weight Change in Adults with Diabetes: A Cohort Study and Meta-analysis (jc.2022-01089)

CONTEXT

Weight management is recognized as critical in reducing cardio-metabolic risk factors for adults with diabetes, but the effects of weight change on cardiovascular disease in patients with diabetes are unknown.

OBJECTIVE

To evaluate 18-month weight change and subsequent risk of macrovascular and microvascular complications in established individuals with type 2 diabetes.

DESIGN AND SETTING

This study consisted of a cohort study and a meta-analysis. In the cohort study, weight change over 18 months was divided into: gain ≥5%, gain 1%-5%, stable (-1%-1%), loss 1%-5%, and loss ≥5%. Cox regression analyses were used to estimate hazard ratios (HR) and 95% confidence intervals (95% CI). We then used random-effect models to pool the results combing our study with other relevant studies.

RESULTS

In the cohort study, 8920 participants with valid weight measurements were included. Compared with patients with stable weight, higher risks were seen in those with weight change for total vascular complications (gain ≥5%: HR=1.43, 95% CI: 1.10-1.85; gain 1-5%: HR=1.44, 95% CI: 1.02-2.03; loss ≥5%: HR=1.58, 95% CI: 1.20-2.08), macrovascular complications (gain ≥5%: HR=1.84, 95% CI: 1.16-2.91; loss 1-5%: HR=1.91, 95% CI: 1.06-3.43; loss ≥5%: HR=2.18, 95% CI: 1.36-3.49) and microvascular complications (loss ≥5%: HR=1.48, 95% CI: 1.06-2.06). Meta-analysis also showed similar results.

CONCLUSIONS

Weight gain and loss over 18 months among patients with type 2 diabetes, especially weight change ≥5%, may be a warning sign of adverse cardiovascular outcomes.

Diabetes-Related Microvascular Complications - A Practical Approach

Diabetes-related microvascular complications include diabetic neuropathy (eg, diabetic symmetric polyneuropathy (DSPN), cardiac autonomic neuropathy, gastroparesis, enteropathy, erectile dysfunction, female sexual dysfunction, and hypoglycemia unawareness), diabetic kidney disease (DKD), and diabetes-related eye disease (eg, diabetic retinopathy (DR) and cataract). Both diabetes duration and degree of glycemic control strongly correlate with the development of microvascular complications. The development of diabetes-related microvascular complications interferes with the patient's quality of life and poses higher health system costs. This article will discuss a practical approach to effectively minimize/delay and manage the most common diabetes-related microvascular (DSPN, DKD, and DR).

Impact of excluding hyperglycemia from international diabetes federation metabolic syndrome diagnostic criteria on prevalence of the syndrome and its association with microvascular complications, in adult patients with type 1 diabetes

BACKGROUND

We aimed to determine, in patients with type 1 diabetes (T1DM), the impact of excluding hyperglycemia as a criterion from the International Diabetes Federation (IDF) definition of the metabolic syndrome (MetS), both on its prevalence and on its association with micro and macrovascular complications and markers of subclinical inflammation.

METHODS

A cross-sectional design, including 280 patients with T1DM. We defined MetS by three different models: (i) the standard IDF criteria, (ii) a modification consisting of excluding of hyperglycemia as a criterion (modified IDF criteria) and (iii) a modification consisting in changing the hyperglycemia by insulin resistance (MetS + IR model) defined by the estimated glucose disposal rate. Microvascular complications and cardioautonomic neuropathy were assessed. We measured an inflammatory panel including high sensitivity C reactive protein, erythrocyte sedimentation rate, homocysteine, and fibrinogen concentrations.

RESULTS

After excluding hyperglycemia, the prevalence of MetS was 6.4% (95%CI: 4.1 to 9.9) compared with 20.7% (95%CI: 16.3 to 25.8) using standard IDF criteria. After adjusting for duration of diabetes, all three MetS definitions increased the odds for having microvascular complications [OR: 6.012 (2.208-16.307) for modified definition; OR: 5.176 (2.555-10.486) for standard definition and [OR: 3.374 (1.649-8.456) for MetS+IR model]. However, the both modified IDF models for MetS showed better predictive performance than standard criteria for suffering from neuropathy, nephropathy, cardiovascular disease and were associated with markers of subclinical inflammation.

CONCLUSIONS

The prevalence of MetS significantly varies as a function whether or not hyperglycemia is included as a diagnostic criterion. The subset of patients fulfilling the modified MetS definitions may reflect better the concept of metabolic syndrome in T1DM. These modified definitions were accompanied by a poorer metabolic control and lipid profile, showing the worse inflammatory biomarker profiles and higher odds for micro- and macrovascular complications. In patients with T1DM, the inclusion of insulin resistance instead of hyperglycemia as a criterion of MetS may be of interest in routine clinical practice.

Predictors of blood glucose change and microvascular complications of type 2 diabetes mellitus patients in Felege Hiwot and Debre Markos referral hospital, North West Ethiopia

BACKGROUND

Microvascular complications lead to disability, dependency, and accelerated morbidity and mortality. This study aimed to identify predictors of blood glucose change and time to microvascular complications among patients with type 2 diabetes.

METHODS

A retrospective cohort study was conducted among type 2 diabetes mellitus patients enrolled between December 2014 and December 2015 at Felege Hiwot and Debre Markos Referral Hospital. A total of 318 T2DM patients were included in the study. Joint modelling of longitudinal and survival analysis was employed to identify predictors of Blood Glucose Change and Microvascular Complications in Type 2 Diabetes Mellitus Patients.

RESULTS

The prevalence of microvascular complications in Type 2 diabetes patients was 26.3%, 95%confidence interval(CI):(21.5, 31.1). Of which, half of the patients developed a microvascular complication after 30 months from the onset of the follow-up. The significant predictors of developing microvascular complication were positive proteinurea (adjusted hazard ratio (AHR) = 1.418, 95%CI: 1.080, 1.861), Serum creatinine (AHR = 3.704, 95%CI: 1.992, 6.887), Weight (AHR = 1.058, 95%CI: 1.023, 1.094), and log fasting blood glucose(log(FBS))(AHR = 1.013, 95%CI: 1.010, 1.015). The predictors of fasting blood glucose progression were higher baseline FBS(est(estimate) = 0.002,95%CI:0.0018, 0.0022), Systolic blood pressure (SBP) (est = 0.003, 95%CI: 0.002, 0.004), diastolic blood pressure (DBP) (est = 0.002, 95%CI: 0.0002, 0.004), and age (est = 0.003, 95%CI: 0.001, 0.004).

CONCLUSION

The progression of the fasting blood glucose level for rural patients was faster than for urban patients. Patients having higher baseline FBS, previous hypertension history, higher SBP, higher DBP, older age, and fewer visits to the hospital have a relatively more progressive change in blood sugar levels. Patients having higher triglyceride levels, positive proteinuria, higher fasting blood sugar, higher weight, and a lesser number of hospital visits have a higher risk of developing a complication. In response to this finding, an aggressive intervention that targets to prevent microvascular complications is required.

The rs705708 A allele of the ERBB3 gene is associated with lower prevalence of diabetic retinopathy and arterial hypertension and with improved renal function in type 1 diabetic patients

INTRODUCTION

The Erb-b2 receptor tyrosine kinase 3 (ERBB3) is involved in autoimmune processes related to type 1 diabetes mellitus (T1DM) pathogenesis. Accordingly, some studies have suggested that single nucleotide polymorphisms (SNPs) in the ERBB3 gene confer risk for T1DM. Proliferation-associated protein 2G4 (PA2G4) is another candidate gene for this disease because it regulates cell proliferation and adaptive immunity. Moreover, PA2G4 regulates ERBB3. To date, no study has evaluated the association of PA2G4 SNPs and T1DM.

AIM

To evaluate the association of ERBB3 rs705708 (G/A) and PA2G4 rs773120 (C/T) SNPs with T1DM and its clinical and laboratory characteristics.

METHODS

This case-control study included 976 white subjects from Southern Brazil, categorized into 501 cases with T1DM and 475 non-diabetic controls. The ERBB3 and PA2G4 SNPs were genotyped by allelic discrimination-real-time PCR.

RESULTS

ERBB3 rs705708 and PA2G4 rs773120 SNPs were not associated with T1DM considering different inheritance models and also when controlling for covariables. However, T1DM patients carrying the ERBB3 rs705708 A allele developed T1DM at an earlier age vs. G/G patients. Interestingly, in the T1DM group, the rs705708 A allele was associated with lower prevalence of diabetic retinopathy and arterial hypertension as well as with improved renal function (higher estimated glomerular filtration rate and lower urinary albumin excretion levels) compared to G/G patients.

CONCLUSIONS

Although no association was observed between the ERBB3 rs705708 and PA2G4 rs773120 SNPs and T1DM, the rs705708 A allele was associated, for the first time in literature, with lower prevalence of diabetic retinopathy and arterial hypertension. Additionally, this SNP was associated with improved renal function.

Urinary albumin/creatinine ratio tertiles predict risk of diabetic retinopathy progression: a natural history study from the Adolescent Cardio-Renal Intervention Trial (AdDIT) observational cohort

AIMS/HYPOTHESIS

We hypothesised that adolescents with type 1 diabetes with a urinary albumin/creatinine ratio (ACR) in the upper tertile of the normal range (high ACR) are at greater risk of three-step diabetic retinopathy progression (3DR) independent of glycaemic control.

METHODS

This was a prospective observational study in 710 normoalbuminuric adolescents with type 1 diabetes from the non-intervention cohorts of the Adolescent Cardio-Renal Intervention Trial (AdDIT). Participants were classified as 'high ACR' or 'low ACR' (lowest and middle ACR tertiles) using baseline standardised log₁₀ ACR. The primary outcome, 3DR, was determined from centrally graded, standardised two-field retinal photographs. 3DR risk was determined using multivariable Cox regression for the effect of high ACR, with HbA_1c, BP, LDL-cholesterol and BMI as covariates; diabetes duration was the time-dependent variable.

RESULTS

At baseline mean ± SD age was 14.3 ± 1.6 years and mean ± SD diabetes duration was 7.2 ± 3.3 years. After a median of 3.2 years, 83/710 (12%) had developed 3DR. In multivariable analysis, high ACR (HR 2.1 [1.3, 3.3], p=0.001), higher mean IFCC HbA_1c (HR 1.03 [1.01, 1.04], p=0.001) and higher baseline diastolic BP SD score (HR 1.43 [1.08, 1.89], p=0.01) were independently associated with 3DR risk.

CONCLUSIONS/INTERPRETATION

High ACR is associated with greater risk of 3DR in adolescents, providing a target for future intervention studies.

TRIAL REGISTRATION

isrctn.org ISRCTN91419926.

Establishment of Zebrafish Models for Diabetes Mellitus and Its Microvascular Complications

Diabetes mellitus (DM) is a chronic metabolic disease known to cause several microvascular complications, including diabetic retinopathy, diabetic nephropathy, and diabetic neuropathy. Hyperglycemia plays a key role in inducing diabetic microvascular complications. A cohort of diabetic animal models has been established to study diabetes-related vascular diseases. However, the zebrafish model offers unique advantages in this field. The tiny size and huge offspring numbers of zebrafish make it amenable to perform large-scale analysis or screening. The easily accessible strategies for gene manipulation with morpholino or CRISPR/Cas9 and chemical/drug treatment through microinjection or skin absorption allow establishing the zebrafish DM models by a variety of means. In addition, the transparency of zebrafish embryos makes it accessible to perform in vivo high-resolution imaging of the vascular system. In this review, we focus on the strategies to establish diabetic or hyperglycemic models with zebrafish and the achievements and disadvantages of using zebrafish as a model to study diabetic microvascular complications.

Effect of metformin as an add-on therapy on neuregulin-4 levels and vascular-related complications in adolescents with type 1 diabetes: A randomized controlled trial

BACKGROUND

Inflammation is closely associated with atherosclerosis and plays a crucial role in the development of cardiovascular disease. Metformin sensitizes body cells to insulin, which may cause a reduction of atherogenic lipid fractions. Low neuregulin-4 (Nrg-4) levels, an adipokine, are linked to obesity, insulin resistance, impaired glucose tolerance and type 2 diabetes.

OBJECTIVES

We assessed the effect of oral supplementation with metformin on glycemic control, neuregulin-4 levels and carotid intima media thickness (CIMT) as a marker for subclinical atherosclerosis in adolescents with type 1 diabetes mellitus (T1DM) and microvascular complications.

METHODS

This randomized placebo-controlled trial included 80 type 1 diabetic patients with microvascular complications who were randomly divided to receive either 24 weeks of metformin 500 mg/day or matching placebo. Fasting blood glucose (FBG), HbA1c, C-reactive protein (CRP), urinary albumin creatinine ratio (UACR), lipid profile, Nrg-4 and CIMT were assessed at baseline and study end.

RESULTS

Both groups were well-matched as regards baseline clinical and laboratory data (p greater than 0.05). After 24-weeks, metformin therapy for the intervention group resulted in a significant decrease of HbA1c, CRP, UACR, total cholesterol and CIMT while Nrg-4 levels were increased compared with baseline levels (p < 0.001) and with placebo group(p < 0.001). Baseline Nrg-4 levels were negatively correlated to FBG, HbA1c, total cholesterol, CRP and CIMT. Metformin was well-tolerated.

CONCLUSIONS

Oral metformin supplementation once daily for 24 weeks as an adjuvant therapy to intensive insulin in pediatric T1DM was safe and effective in improving glycemic control, dyslipidemia and Nrg-4 levels; hence, it decreased inflammation, microvascular complications and subclinical atherosclerosis.

Preventative diabetes self-care management practices among individuals with diabetes and mental health stress

BACKGROUND

The study purpose examines diabetes self-care management practices among individuals diagnosed with diabetes with and without mental health stress.

METHODS

Pooled cross-sectional data (2011-2016) from the Household Component of the Medical Expenditure Panel Survey (HC-MEPS) were used. The sample consisted of individuals ages 25-85 years (n = 13,193; weighted n = 23,559,975). Dependent variables were engagement in moderate/vigorous physical exercise five times weekly, receiving dilated eye exams, foot checks, treating diabetes with diet modification or insulin injections, and eating fewer high fat/cholesterol foods. The independent variable was diabetes with and without mental health stress. The study controlled for predisposing, enabling, and need factors.

RESULTS

Compared with individuals with diabetes without mental health stress, findings indicate individuals with diabetes and low or mild/moderate mental health stress were more likely to treat diabetes with diet modification and to restrict high fat/cholesterol food. Individuals with diabetes and severe mental health stress were more likely to restrict high fat/cholesterol. Additionally, individuals with mild/moderate to severe mental health stress were less likely to engage in diabetes care behavior.

LIMITATIONS

Mental health stress is represented as a non-specific psychological distress index summary during the past 30 days and may not be an actual representation of overall distress in a person's life. There were no variables distinguishing diabetes type or severity. The study uses self-reported data and is cross-sectional.

CONCLUSIONS

Mental health stress may contribute to individuals not engaging in self-management practices. It would be beneficial to incorporate psychosocial services for individuals with diabetes and mental health stress.

Differential effects of treatment targets on risks of adverse outcomes according to diabetes duration, age and complications: Can these characteristics be used to individualize diabetes treatment? The Rio de Janeiro type 2 diabetes cohort

AIMS

To investigate interactions between more/less strict treatment targets (HbA_1c, systolic blood pressure, LDL-cholesterol) and clinical characteristics (age, diabetes duration and presence of complications) for occurrence of cardiovascular/microvascular complications and mortality in type 2diabetes.

METHODS

690 individuals were followed-up for 10 years (median). Interactions between treatment targets, estimated as mean values during the first 2-years, and clinical characteristics were tested in multivariable Cox regressions adjusted for other risk factors. Hazard ratios (HRs) were estimated in stratified analyses for cardiovascular/microvascular outcomes and mortality.

RESULTS

During follow-up, 214 patients had a cardiovascular event (175 MACEs); and 265 died (132 cardiovascular deaths); there were 206 renal, 161 retinopathy and 181 peripheral neuropathy events. There were interactions between treatment parameters and clinical characteristics, in most of them the HRs were higher in older individuals, in those with longer diabetes durations and with complications, particularly for the cardiovascular outcomes and mortality. For microvascular outcomes the opposite was observed. For cardiovascular mortality, the HRs of higher HbA_1c were 1.31 (1.08-1.58) and 1.09 (0.88-1.34), respectively with longer/shorter diabetes duration (p-for-interaction 0.11); and 1.43 (1.14-1.79) and 1.02 (0.85-1.23) in older/younger individuals (p-for-interaction 0.019).

CONCLUSIONS

Our findings do not support less strict treatment targets for older individuals, with longer diabetes duration or with complications, particularly for cardiovascular and mortality prevention.

Association of periodontitis with microvascular complications of diabetes mellitus: A nationwide cohort study

BACKGROUND

Periodontitis is a common chronic inflammatory disease and one of oral complications in diabetes. Diabetes-related microvascular complications and periodontitis are also closely related to systemic inflammation. We hypothesized that periodontitis and oral hygiene markers might increase the risk of microvascular complications in diabetes mellitus.

METHODS

We enrolled 11,353 diabetes participants without prior microvascular complications who received complete oral health checkups in the National Health Insurance Service-National Health Screening Cohort in 2003-2004. The primary outcome was the first development of diabetes-related microvascular complications, including nephropathy, neuropathy, and retinopathy.

RESULTS

The age of all participants was 55.27 ± 9.46 years, and 7833 (68.99%) participants were male. Periodontitis was noted in 8.37%. During the 7.03 ± 4.30 year of the mean follow-up period, 7227 patients experienced diabetes-related microvascular complications (2645 with nephropathy, 2513 with neuropathy, 2069 with retinopathy). Multivariable Cox regression analyses revealed that periodontitis was an independent risk factor for diabetes-related microvascular complications (adjusted hazard ratio (HR):1.13; 95% confidence interval (CI):1.04-1.23; p = 0.004). In the secondary analysis for individual microvascular complications, periodontitis was an independent risk factor for retinopathy (adjusted HR: 1.21; 95% CI: 1.04-1.40; p = 0.013).

CONCLUSIONS

The presence of periodontitis was associated with an increased risk of microvascular complications in diabetes patients.

Role of miRNAs in diabetic neuropathy: mechanisms and possible interventions

Accelerating cases of diabetes worldwide have given rise to higher incidences of diabetic complications. MiRNAs, a much-explored class of non-coding RNAs, play a significant role in the pathogenesis of diabetes mellitus by affecting insulin release, β-cell proliferation, and dysfunction. Besides, disrupted miRNAs contribute to various complications, diabetic retinopathy, nephropathy, and neuropathy as well as severe conditions like diabetic foot. MiRNAs regulate various processes involved in diabetic complications like angiogenesis, vascularization, inflammations, and various signaling pathways like PI3K, MAPK, SMAD, and NF-KB signaling pathways. Diabetic neuropathy is the most common diabetic complication, characterized mainly by pain and numbness, especially in the legs and feet. MiRNAs implicated in diabetic neuropathy include mir-9, mir-106a, mir-146a, mir-182, miR-23a and b, miR-34a, and miR-503. The diabetic foot is the most common diabetic neuropathy, often leading to amputations. Mir-203, miR-23c, miR-145, miR-29b and c, miR-126, miR-23a and b, miR-503, and miR-34a are associated with diabetic foot. This review has been compiled to summarize miRNA involved in initiation, progression, and miRNAs affecting various signaling pathways involved in diabetic neuropathy including the diabetic foot. Besides, potential applications of miRNAs as biomarkers and therapeutic targets in this microvascular complication will also be discussed.

Involvement of Cdkal1 in the etiology of type 2 diabetes mellitus and microvascular diabetic complications: a review

Diabetes Mellitus, being a polygenic disorder, have a set of risk genes involved in the onset of the insulin resistance, obesity and impaired insulin synthesis. Recent genome wide association studies (GWAS) shows the intimacy of CDK5 regulatory subunit Associated protein 1-Like 1 (Cdkal1) with the pathophysiology of the diabetes mellitus and its complications, although the exact molecular relation is still unknown. In this short review, we have summarized all the diverse biological roles of Cdkal1 in relation to the onset of diabetes mellitus. Variations in the Cdkal1 transcript are responsible for the accumulation of misfolded insulin and thus generating oxidative and ER stress in the pancreatic β-cells, leading to their destruction. Recent studies have shown that Cdkal1 has an intrinsic thiomethyl transferase activity, which is essential for proper posttranslational processing of pre-proinsulin to produce mature insulin. Moreover, Cdkal1 has also been claimed as an endogenous inhibitor of cdk5, which prevents the cdk5-induced interruption in insulin synthesis through PDX1 translocation from nucleus to cytosol. Recent clinical studies have identified the risk single nucleotide polymorphisms (SNPs) of Cdkal1 as one of the root causes for the onset of diabetic complications. To the best of our knowledge, it is the first comprehensive review which elaborates most of the potential Cdkal1-dependent molecular mechanisms studied yet. In this review, we present a compiled and concise summary about all the diverse roles of Cdkal1 in the context of type 2 diabetes mellitus and its associated complications. This review will be helpful to target Cdkal1 as a potential option for the management of type 2 diabetes mellitus in future.

Graphical abstract